Combined systemic and topical treatment of disordered tissues

ABSTRACT

Kits and methods for treating disordered or infected tissue caused by a virus in a mammal involve co-administering a systemic anti-virus drug and topically administered anti-infective composition. The systemic anti-virus drug is internally administered and disrupts or inhibits virus replication systemically within the mammal. Examples include nucleoside analogues, nucleoside analogue precursors, and nucleotide analogues. The topically administered anti-infective composition includes at least one anti-infective agent, such as an organohalide (e.g., benzalkonium chloride), and is formulated to penetrate below the skin surface and allow the anti-infective agent to kill viruses at the infected tissue site. The topical anti-infective composition renders the systemic anti-virus drug more efficacious and reduces the time and/or number of dosages otherwise required for the systemic anti-virus drug to treat the disordered tissue. In some cases, the topical anti-infective composition is more beneficial than the systemic anti-virus drug in killing viruses and can reduce or eliminate post-herpetic neuralgia.

CROSS REFERENCE TO RELATED APPLICATION

This application is a division of U.S. patent application Ser. No.13/804,002, filed Mar. 14, 2013, the disclosure of which is incorporatedherein in its entirety.

BACKGROUND OF THE INVENTION

1. The Field of the Invention

The present invention relates to kits and methods for treatingdisordered tissues caused by a virus, such as herpes virus, that combinesystemic and topical treatments.

2. The Relevant Technology

Tissue disorders caused by viruses, particularly those which impactepithelial tissue, include Herpes simplex virus types I and II, herpeszoster, varicella-zoster, cytomegalovirus, and HHV-8, which causesKaposi's Sarcoma. Such viruses can cause painful, disfiguring and/orhighly infectious disordered tissues (e.g., blisters or lesions), whichare physically and psychologically debilitating. Disordered tissuescaused by viruses are often difficult to treat and can last a lifetime.

Herpes simplex virus types I and II and herpes varicella-zoster,commonly referred to as “herpes virus” or “herpes,” are infectiousdiseases which have reached crisis proportions nationally with estimatednumbers of infected people at 70%-80% of U.S. population as reported bythe American Social Health Association (ASHA) and growing annually by500,000 people or more.

Herpes enters the human body through minuscule breaks in the epidermaltissue usually by contact with an infected host and is marked byeruption of one or more vesicles, usually in groups, following anincubation period of approximately four to ten days. Typically thecourse of the infectious outbreak initiates with the prodromal stage,advancing to vesicular eruption, followed by ulceration, coalescing,resolution, and latency period. The outbreak can last for several weeksand, on average, lasts two to three weeks. In some immune compromisedindividuals, outbreaks can last for months. The lesions caused byvaricella-zoster (shingles) can last 21 days or longer. The vesicles canappear anywhere on epithelial tissues including the skin or mucosa,typically appearing on the lips as cold sores, glands, oral mucosa,conjunctiva and cornea, genitalia, anal mucosa and peri-anal tissue.

Herpes symptoms include: inguinal swelling, pain, fever, malaise,headaches, muscle aches, and swollen glands. Some individuals with oralherpes, which impacts the trigeminal nerve, have excruciating facialpain, difficulty swallowing, eating and facial swelling. Individualswith the herpes which impacts the sacral nerve have severe upper legpain, swelling, and great difficulty walking.

Herpes is recurring, residing in the nerve ganglia, then recurring dueto some, as yet unknown, stimulus mechanism. Recurrent herpeticinfections can be precipitated by almost anything, includingoverexposure to sunlight, nutritional deficiencies, stress,menstruation, immunosuppression, certain foods, drugs, febrile illness,suppression of the immune system, and the like.

Herpes infections pose serious health threats, often causing blindness,increased cancer risk of the cervix, aseptic meningitis andencephalitis, neonatal deaths, viremia, the spread of the humanimmunodeficiency virus (HIV), and the like. The devastating effects ofherpes diseases go well beyond the medical scope of human suffering.Herpes can be responsible for serious psychological and emotionaldistress as well as substantial economic loss. Other viral diseases aretransmitted in different manners and may have different symptoms but canbe as painful emotionally and physically to a patient.

The most common (and only FDA-approved) therapeutic treatment ofherpetic or other viral disorders is through systemic treatment, such asusing nucleoside analogs or other drugs that inhibit or interruptreplication of the virus causing the disorder. Systemic treatments canbe taken orally or intravenously and can prevent or inhibit outbreaks.Systemic treatment generally inhibits or disrupts the reproductive cycleof the target virus. However, systemic treatments can take a significantamount of time to metabolize and convert into the active form. Once inactive form, they must be delivered throughout a patient's entire bodyto eliminate the virus. During the time required to deliver themedication to the patient's body, the patient can still experienceoutbreaks that cause significant discomfort while the patient waits forthe medication to take effect. In addition, the stratum basal layer canprevent medication from passing through to the epidermis so thatinfected regions of the epidermis continue to experience the outbreakcycle. Hence, systemic treatments may be ineffective in treating anexisting outbreak of skin lesions, including the pain and discomfortexperienced by the patient. Furthermore, a person can re-infectthemselves by touching an infected outbreak area (even while taking asystemic medication) and exposing another area of their body with thevirus.

In contrast to systemic treatments, topical treatments are intended toreduce the pain and severity associated with disordered tissues causedby herpes or other viruses. They can be soothing as a salve over thetender surface of the disordered tissue. However, they rarely if everprovide actual therapeutic treatment of the underlying cause of thedisorder, which is the system-wide existence of virus in the person'sbody.

In view of the widespread nature of herpes and other viral causeddisordered tissues, coupled with the general ineffectiveness of existingtreatments, there exists an ongoing need to develop effective treatmentsthat can shorten, reduce or eliminate outbreaks of disordered tissues.

BRIEF SUMMARY

Disclosed herein are kits and methods for treating disordered tissuecaused by a virus in a human that involve co-administration of asystemic anti-virus drug and topically administering an anti-infectivecomposition. It has now been discovered that administering anappropriate topical treatment together with a systemic anti-virus drugcan synergistically work together to increase the effectiveness of thesystemic treatment in order to shorten the duration of the outbreak,reduce or eliminate future outbreaks, and reduce or eliminatepost-herpetic neuralgia (a condition that causes the patient toexperience pain weeks, months, years, or decades after the lesions havehealed).

The systemic anti-virus drug can be administered internally, such asorally or intravenously, and is designed to disrupt or inhibit virusreplication within the human body. Examples include nucleosideanalogues, nucleoside analogue precursors, and nucleotide analogues. Thetopically administered treatment is a penetrating anti-infectivecomposition which includes at least one anti-infective agent, such as anorganohalide (e.g., benzalkonium chloride) and which is formulated topenetrate below the disordered tissue surface and kill viruses at thedisordered tissue site without entering the bloodstream. Theanti-infective composition reduces the time and/or number of dosages ofsystemic anti-virus drug required to treat the disordered tissue and itsunderlying cause. It also reduces or eliminates nerve damage, which cancause post-herpetic neuralgia when used together with a systemicanti-viral drug.

This is surprising and unexpected since topical herpes treatments areconsidered to be merely temporary soothing agents rather than drugs thatare systemically effective in killing viruses. It is postulated thatthat during an outbreak that causes disordered tissue lesions, adisproportionately large number of the viruses within the patient's bodyare concentrated near the skin surface at the disordered tissue site. Itis further postulated that inactivating such viruses topically byadministering a penetrating anti-infective composition reduces theoverall number of viruses in the patient's body that must be treated bythe systemic drug, thereby significantly reducing the amount of timeand/or dosages of systemic anti-virus drug that would otherwise berequired to treat the outbreak using the systemic drug by itself. Inaddition, it is postulated that, to the extent the stratum basal layerinhibits systemically administered medication from passing through tothe epidermis, topically treating and deactivating viruses at thedisordered tissue site may be more effective than deactivation of suchviruses using a systemic treatment. The result is synergistic dualtreatment of the disease by the systemic treatment, which is highlyeffective in treating viruses internally but less effective in treatingviruses near the skin surface, coupled with topical treatment of thedisordered tissue at the skin surface using a penetrating anti-infectivecomposition, which is effective in deactivating viruses near the skinsurface but not internally beyond the disordered tissue site.

Further synergy is exhibited in that co-administration of a systemicanti-viral drug and a topically administered penetrating anti-infectivecomposition also reduces or eliminates nerve damage, which can causePost-Herpetic Neuralgia (PHN). This is unexpected since systemicanti-viral drugs on their own can often resolve the acute symptomsassociated with disordered tissues yet not prevent nerve damage and/orchronic neuralgia, which is an extremely painful neurological conditionfor which there is no known cure.

An example method of treating disordered tissues caused by viruses in amammal includes: (1) internally administering an effective amount of asystemic anti-virus drug to a mammal in need thereof in order to disruptor inhibit virus replication systemically; and (2) topicallyadministering an anti-infective composition comprising at least oneanti-infective agent to the disordered tissue in order for thecomposition to penetrate below the disordered tissue surface and allowthe anti-infective agent to deactivate viruses at the disordered tissuesite.

An example kit for use in treating disordered tissues caused by a virusin a mammal includes: (1) an effective amount of an orally administeredsystemic anti-virus drug that, when administered to a mammal in needthereof, disrupts or inhibits virus replication systemically; and (1) atopically administered penetrating anti-infective composition comprisingan anti-infective agent and a tissue penetrating liquid carrier thatpromotes penetration of the anti-infective composition into thedisordered tissue and below the surface so as to allow theanti-infective composition to kill viruses at the disordered tissuesite.

Topically administering the anti-infective composition can reduce theduration and/or number of dosages of the systemic anti-virus drug by atleast about 10% compared to treatment of the disordered tissue by theanti-virus drug alone, in the absence of co-administering ananti-infective composition topically, preferably by at least about 20%,more preferably by at least about 30%, and most preferably by at leastabout 40%. Co-administration of systemic and topical treatments can alsoreduce or eliminate post-herpetic neuralgia, which is a common symptomeven after successful resolution of disordered tissue using anti-viraldrugs. Moreover, the treatment may involve only 5 applications or lessof the topically-applied anti-infective composition throughout theentire treatment process, preferably 3 dosages or less, more preferably2 dosages or less, and most preferably a single dosage.

According to one embodiment, the anti-infective composition may includeat least one topical anesthetic that not only reduces pain but enhancespenetration of the anti-infective composition into the disordered tissueand to accelerate deactivation of viruses and healing of the disorderedtissue.

This Brief Summary is provided to introduce in a simplified form aselection of concepts that are further described below in the DetailedDescription. This Brief Summary is not intended to identify key oressential features of the claimed subject matter, nor is it intended tobe used as an aid in determining the scope of the claimed subjectmatter. Additional features and advantages of the invention will be setforth in the description which follows, and in part will be evident topersons of ordinary skill in the art from the description and appendedclaims, or may be learned by such persons through the practice of theinvention.

BRIEF DESCRIPTION OF THE DRAWINGS

In order to describe the manner in which the above-recited and otheradvantages and features of the invention can be obtained, a moreparticular description of the invention briefly described above will berendered by reference to specific embodiments thereof which areillustrated in the appended drawings. It should be noted that thefigures are not necessarily drawn to scale, and that elements of similarstructure or function are generally represented by like referencenumerals for illustrative purposes throughout the figures. Thesedrawings depict only certain embodiments of the invention and are nottherefore to be considered to be limiting of its scope.

FIG. 1 is a vertical cross-section of the epidermis and the papillae ofthe dermis;

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS I. Introduction

The present invention is directed to methods for kits for treatingdisordered tissues caused by a virus, particularly those which impactepithelial tissue such as Herpes simplex virus types I and II, herpeszoster, or varicella-zoster, or HHV-8, which causes Kaposi's Sarcoma.The method generally includes (1) administering an effective amount of asystemic anti-virus drug to a mammal in need thereof in order to disruptor inhibit virus replication systemically within the body and (2)topically administering an anti-infective composition to the disorderedtissue in order for the composition to penetrate below the surface andallow the anti-infective agent to kill viruses at the disordered tissuesite. Surprisingly and unexpectedly, topically administering theanti-infective composition reduces the amount of time and/or number ofdosages required for the systemic anti-virus drug to treat theunderlying virus disorder compared to only administering the systemicanti-virus drug by itself in the absence of topically administering theanti-infective composition.

Further synergy is exhibited in that co-administration of a systemicanti-viral drug and a topically administered penetrating anti-infectivecomposition also reduces or eliminates nerve damage, which can causepost-herpetic neuralgia. This is unexpected since systemic anti-viraldrugs on their own can often resolve the acute symptoms associated withdisordered tissues yet not prevent nerve damage and/or chronicneuralgia, which is an extremely painful neurological condition forwhich there is no known cure.

II. Compositions for Systemic Treatment

As used herein, “systemic treatment” refers to administration of ananti-virus drug internally (i.e., inside the body) to a patient.Administration may be oral and/or parenteral (e.g., subcutaneous,intramuscular, intravenous, intradermal, intrathecal and/or epiduraladministration). Systemic treatments generally affect the body on asystem-wide basis rather than on a local level. Systemic compositionsmay include one or more components comprising active agents, carriersand/or therapeutic components, as will now be described.

A. Active Agent for Systemic Treatments

The active agents of the systemic compositions can include one or moreanti-virus drugs. Such drugs act to disrupt or inhibit the replicationof herpes and herpes-related viruses. Examples of anti-virus drugs thatare useful for systemic treatments include nucleoside analogues,nucleoside analogue precursors, and nucleotide analogues, which mimicnucleosides or nucleotides required for virus replication but are notthe actual nucleosides or nucleotides required for successful or healthyvirus replication. Examples of nucleoside analogues include, but are notlimited to,

-   aciclovir (alternatively spelled “acyclovir”) (acycloguanosine)    (2-Amino-1,9-dihydro-9-((2-hydroxyethoxy)methyl)-6H-purin-6-one)    (alternatively spelled “acyclovir”),-   penciclovir    (2-amino-9-[4-hydroxy-3-(hydroxymethyl)butyl]-6,9-dihydro-3H-purin-6-one)    (sold under the trademark Denavir®),-   famciclovir (2-[(acetyloxy)methyl]-4-(2-amino-9H-purin-9-yl)butyl    acetate) (sold under the trademark Famvir®),-   idoxuridine    (1-[(2R,4S,5R)-4-hydroxy-5-(hydroxymethyl)oxolan-2-yl]-5-iodo-1,2,3,4-tetrahydropyrimidine-2,4-dione),-   ganciclovir    (2-amino-9-{[(1,3-dihydroxypropan-2-yl)oxy]methyl}-6,9-dihydro-3H-purin-6-one)    (sold under the trademark Cytovene®),-   cidofovir    (({[(S)-1-(4-amino-2-oxo-1,2-dihydropyrimidin-1-yl)-3-hydroxypropan-2-yl]oxy}methyl)phosphonic    acid) (sold under the trademark Vistide®), and-   derivatives thereof.

An example of a nucleoside analogue precursor (i.e., which is convertedinto the nucleoside analogue aciclovir in vivo) includes valaciclovir(S)-2-[(2-amino-6-oxo-6,9-dihydro-3H-purin-9-yl)methoxy]ethyl-2-amino-3-methylbutanoate)(sold under the trademark Valtrex®) and derivatives thereof. Examples ofnucleotide analogues include, but are not limited to, adefovir({[2-(6-amino-9H-purin-9-yl)ethoxy]methyl}phosphonic acid) (sold underthe trademark Hepsera®), tenofovir(({[(2R)-1-(6-amino-9H-purin-9-yl)propan-2-yl]oxy}methyl)phosphonicacid) (sold under the trademark Viread®), and derivatives thereof.

Also contemplated are inhibitors of herpesvirus DNA replication (e.g.,4-oxo-dihydroquinones), possible inhibitors of herpesvirus geneexpression (e.g., fomivirsen, pyrazoloquinoline, and benzothiophene),inhibitors of herpesvirus assembly, encapsidation and nuclear egress(e.g., acridones, thiourea inhibitors, phenylenediamine-sulfonamides,and ribosylbenzimazoles), inhibitors of cellular proteins that blockviral replication (e.g., CDK inhibitors, such roscovitine) andcyclooxygenase inhibitors (e.g., BMS-279652, BMS-279654, BMS-279655),and forscarnet (phosphonoformic acid).

Aciclovir has been widely studied for its anti-viral properties. Thechemical formulation of acyclovir is 9-(2-hydroxyethoxymethyl)guanine,which has the structure:

Aciclovir phosphate derivatives can also be used in systemiccompositions, examples of which include:

-   aciclovir monophosphate (ACV-MP);-   aciclovir diphosphate (ACV-DP);-   aciclovir monophosphate glycerol (ACV-MP-G);-   aciclovir diphosphate glycerol (ACV-DP-G);-   aciclovir monophosphate morpholidate (ACV-MP-morpholine);-   aciclovir monophosphate isopropylidene glycerol (ACV-MP-isoP-G); and-   aciclovir diphosphate isopropylidene glycerol (ACV-DP-isoP-G).    Methods for making the above aciclovir phosphate derivatives are    taught in U.S. Pat. No. 5,580,571, herein incorporated by reference.

Other aciclovir derivatives can be formed from purinyl and pyrimidinyltetrahydrofurans to enhance anti-viral activity. These derivatives caninclude:

-   3R-(3α,4β,5α)]-2-Amino-1,9-dihydro-9-tetrahydro-4-hydroxy-5-(hydroxymethyl)-3-furanyl]-6H-purin-6-one;-   [2R-[2α(S*),3α,4β]]-Tetrahydro-β3,4-trihydroxy-2-furanethanol;-   [2S-(2α,3α,4β)]-Tetrahydro-3,4-dihydroxy-2-furancarboxaldehyde;-   [2R-(2α,3α,4β)]-Tetrahydro-3,4-dihydroxy-2-furanmethanol;-   [4aR-(4aα,7α,7aα)]-Tetrahydro-2,2-dimethyl-4H-furo[3,2-d]-1,3-dioxin-7-ol;-   [4aR-(4aα,7α,7aα)]-Tetrahydro-2,2-dimethyl-4H-furo[3,2-d]-1,3-dioxin-7-ol,    acetate ester;-   [2R-(2α,3α,4β)]-Tetrahydro-3,4-dihydroxy-2-furanmethanol, 4-acetate    ester;-   [2R-(2α,3α,4β)]-Tetrahydro-2-[[(4-methoxyphenyl)diphenylmethoxy]methyl]-3,4-furandiol,    4-acetate ester;-   [2R-(2α,3α,4β)]-Tetrahydro-2-[[(4-methoxyphenyl)diphenylmethoxy]methyl]-3,4-furandiol,    4-acetate, 3-methanesulfonate ester;-   [2R-(2α,3β,4β)]-3,4-Epoxytetrahydro-2-[[(4-methoxyphenyl)diphenylmethoxy]methyl]furan;-   [3R-(3α,4β,5β]-6-(phenylmethoxy)-9-tetrahydro-4-hydroxy-5-[[(4-methoxyphenyl)diphenylmethoxy]methyl]-3-furanyl]-9H-purin-2-amine;-   [3R-(3α,4β,5α)]-2-Amino-1,9-dihydro-9-tetrahydro-4-hydroxy-5-(hydroxymethyl)-3-furanyl]-6H-purin-6-one;-   [3R-(3α,4β,5α)]-5-Methyl-1-[tetrahydro-4-hydroxy-5-(hydroxymethyl)-3-furanyl]2,4(1H,3H)pyrimidinedione;-   [2R-[2α(S*),3α,4β]]-Tetrahydro-β,3,4-trihydroxy-2-furanethanol;    [4aR(4aα,7α,7aα)]-Tetrahydro-2,2-dimethyl-4H-furo[3,2-d]-1,3-dioxin-7-ol;    [4aR-(4aα,7α,7aα)]-Tetrahydro-2,2-dimethyl-4H-furo[3,2-d]-1,3-dioxin-7-ol,    acetate ester;-   [2R-(2α,3α,4β)]-Tetrahydro-3,4-dihydroxy-2-furanmethanol, 4-acetate    ester;-   [2R-(2α,3α,4β)]-Tetrahydro-2-[(4-methoxyphenyl)diphenylmethoxy]methyl]-3,4-furandiol,    4-acetate ester;-   2R-(2α,3α,4β)]-Tetrahydro-2-[[(4-methoxyphenyl)diphenylmethoxy]methyl]-3,4-furandiol,    4-acetate, 3-methanesulfonate ester;-   [2R-(2α,3β,4β)]-3,4-Epoxytetrahydro-2-[[(4-methoxyphenyl)diphenylmethoxy]-methyl]furan;-   [3R-(3α,4β,5α)]-5-Methyl-1-[tetrahydro-4-hydroxy-5-[[(4-methoxyphenyl)diphenylmethoxy]methyl]-3-furanyl]-2,4    (1H,3H)pyrimidinedione;-   [3R-(3α,4β,5α)]-5-Methyl-1    [tetrahydro-4-hydroxy-5-(hydroxymethyl)-3-furanyl]-2,4-(1H,3H)pyrimidinedione;-   [3R-(3α,4β,5α)]-4-Amino-1-[tetrahydro-4-hydroxy-5-(hydroxymethyl)-3-furanyl]-2(1H)-pyrimidinone;-   [3R-(3α,4β,5α)]-4-Amino-1-[tetrahydro-4-hydroxy-5-[[(4-methoxyphenyl)diphenylmethoxy]methyl]-3-furanyl]-2(1H)-pyrimidinone;-   3R-(3α,4β,5α)]-4-Amino-1-[tetrahydro-4-hydroxy-5-(hydroxymethyl)-3-furanyl]-2(1H)-pyrimidinone;-   [3R-(3α,4β,5α)]-1-[Tetrahydro-4-hydroxy-5-(hydroxymethyl)-3-furanyl]-2,4(1H,3H)pyrimidinedione;-   [2R-(2α,3β,4β)]Tetrahydro-2-[(triphenylmethoxy)methyl]-3,4-furandiol;-   [3    aR-(3aα,4α,6aα)]-Tetrahydro-4-[(triphenylmethoxy)methyl]furo[3,4-d]-1,3,2-dioxathiole,    2,2-dioxide;-   [3R-(3α,4β,5α)]-1-[Tetrahydro-4-hydroxy-5-[(triphenylmethoxy)methyl]-3-furanyl]-2,4(1H,3H)-pyrimidinedione;    and-   [3R-(3α,4β,5α)]-1-Tetrahydro-4-hydroxy-5-(hydroxymethyl)-3-furanyl]-2,4(1H,3H)pyrimidinedione.    Methods for producing pharmaceutically acceptable formulations of    the above aciclovir derivatives are taught in U.S. Pat. No.    5,272,152, herein incorporated by reference.

In one embodiment, the active agent is an amino acid ester of aciclovir.Amino acid esters of aciclovir include glycine, alanine, valine esters.For example, the valine ester of aciclovir, also referred to asvalaciclovir), has been shown in U.S. Pat. No. 4,957,924, hereinincorporated by reference, to have improved bioavailability in oraladministration. Valaciclovir can be converted to aciclovir and are thusanalogs of each other. Further, aciclovir is a metabolite ofvalaciclovir in that valaciclovir may also be converted to aciclovirduring internal metabolization and distributions thereof. The chemicalformula of valaciclovir is2-(2-amino-1,6-dihydro-6-oxo-(H(purin-9-yl)methoxy)ethyl L-valinate,which has the structure:

Also contemplated are pharmaceutically acceptable salts thereof.Suitable valaciclovir derivatives include:

-   2-[(2-Amino-1,6-dihydro-6-oxo-9H-purin-9-yl)methoxy]ethyl    N-[(benzyloxy)carbonyl]L-valinate;-   2-[(2-Amino-1,6-dihydro-6-oxo-9H-purin-9-yl)methoxy]ethyl    L-valinate;-   2-(2-Amino-1,6-dihydro-6-oxo-9H(purin-9-yl)methoxy)ethyl L-valinate    hydrochloride monohydrate;-   2-[(2-Amino-1,6-dihydro-6-oxo-9H-purin-9-yl)methoxy]ethyl    N-[(benzyloxy)carbonyl]L-valinate; and-   2-[(2-Amino-1,6-dihydro-6-oxo-9H-purin-9-yl)methoxy]ethyl L-valinate    hydrochloride monohydrate.

Methods for producing pharmaceutically acceptable formulations ofvalaciclovir and pharmaceutically acceptable salts thereof are describedin U.S. Pat. No. 4,957,924, herein incorporated by reference.

Penciclovir is another derivative of aciclovir. The chemical formula ofpenciclovir is 9-[4-Hydroxy-3-(hydroxymethyl)butyl]guanine, which hasthe chemical structure:

Also contemplated are pharmaceutically acceptable salts, phosphateester, or acyl derivative thereof. Example derivatives are where the oxogroup is replaced with chlorine, straight or branched chain C₁₋₆ alkoxy,preferably methoxy, phenoxy, phenyl C₁₋₆ alkoxy, —NH₂, —OH or —SH, withthe proviso that when the oxo group is replaced with OH, the compound ofpenciclovir is in a purity state of greater than 50% by weight of purecompound. Suitable derivatives of penciclovir include:

-   2-Amino-1,9-dihydro-9-[4-hydroxy-3-(hydroxymethyl)but-1-yl]-6H-purine;-   5-(2-Hydroxyethyl)-2,2-dimethyl-1,3-dioxan;-   5-(2-Bromoethyl)-2,2-dimethyl-1,3-dioxan;-   2-Amino-6-chloro-9-[2-(2,2-dimethyl-1,3-dioxan-5-yl)ethyl]-purine;-   9-(4-Hydroxy-3-hydroxymethylbut-1-yl)guanine;-   Ethyl 4-benzyloxy-2-ethoxycarbonylbutanoate;-   4-Benzyloxy-2-hydroxymethylbutan-1-ol;-   2-Acetoxymethyl-4-benzyloxybut-1-yl acetate;-   2-Acetoxymethyl-4-hydroxybut-1-yl acetate;-   2-Acetoxymethyl-4-bromobut-1-yl acetate;-   9-(4-Acetoxy-3-acetoxymethylbut-1-yl)-2-amino-6-chloropurine;-   7-(4-Acetoxy-3-acetoxymethylbut-1-yl)-2-amino-6-chloropurine;-   9-(4-Hydroxy-3-hydroxymethylbut-1-yl)guanine, sodium salt;-   9-(4-Hydroxy-3-hydroxymethylbut-1-yl)guanine, potassium salt;-   2-Amino-6-chloro-9-(4-hydroxy-3-hydroxymethylbut-1-yl)purine    hydrochloride;-   2-Amino-9-(4-hydroxy-3-hydroxymethylbut-1-yl)-6-methoxypurine;-   2-Amino-6-ethoxy-9-(4-hydroxy-3-hydroxymethylbut-1-yl)purine;-   2-Amino-6-benzyloxy-9-(4-hydroxy-3-hydroxymethylbut-1-yl) purine;-   2-Amino-9-(4-hydroxy-3-hydroxymethylbut-1-yl)-6-thiopurine;-   2-Amino-6-azido-9-[2-(2,2-dimethyl-1,3-dioxan-5-yl)ethyl]-purine;-   2,6-Diamino-9-[2-(2,2-dimethyl-1,3-dioxan-5-yl)ethyl]purine;-   2,6-Diamino-9-(4-hydroxy-3-hydroxymethylbut-1-yl)purine;-   9-(4-Acetoxy-3-acetoxymethylbut-1-yl)guanine;-   9-(4-Propionyloxy-3-propionyloxymethylbut-1-yl)guanine;-   N²-Propionyl-9-(4-propionyloxy-3-propionyloxymethyl-but-1-yl)guanine;-   9-(4-Hexanoyloxy-3-hexanoyloxymethylbut-1-yl)guanine;-   9-(4-Formyloxy-3-formyloxymethylbut-1-yl)guanine;-   9-[4-(N-Imidazolylcarbonyloxy)-3-(N-imidazolylcarbonyloxymethyl)-but-1-yl]guanine;-   N²-Monomethoxytrityl-9-(4-monomethoxytrityloxy-3-hydroxymethylbut-1-yl)guanine;-   N²-Monomethoxytrityl-9-(4-hydroxy-3-hydroxymethylbut-1-yl)-guanine;-   9-(4-Pivalyloxy-3-pivalyloxymethylbut-1-yl)guanine;-   9-(4-Acetoxy-3-hydroxymethylbut-1-yl)guanine;-   9-(4-Benzoyloxy-3-hydroxymethylbut-1-yl)guanine;-   9-(4-Hexanoyloxy-3-hydroxymethylbut-1-yl)guanine;-   9-(4-Hexadecanoyloxy-3-hydroxymethylbut-1-yl)guanine;-   9-(4-Hydroxy-3-hydroxymethylbut-1-yl)guanine 4′-phosphate diammonium    salt;-   N²-Acetyl-9-(4-hydroxy-3-hydroxymethylbut-1-yl)guanine;-   N²-Hexanoyl-9-(4-hydroxy-3-hydroxymethylbut-1-yl)guanine;-   2-Amino-9-(4-hydroxy-3-hydroxymethylbut-1-yl)-6-isopropoxypurine;    and-   2-Amino-9-(4-hydroxy-3-hydroxymethylbut-1-yl)-6-phenoxypurine.    Methods for producing pharmaceutically acceptable formulations of    penciclovir and derivatives are described in detail in U.S. Pat. No.    5,075,445, herein incorporated by reference.

Famciclovir is another derivative of aciclovir and can be converted topenciclovir. The chemical formula for famciclovir is9-(4-hydroxy-3-hydroxymethylbutyl)guanine, which has the chemicalstructure:

Also contemplated are pharmaceutically acceptable salts thereof as wellas derivatives of famciclovir. Suitable derivatives of famciclovirinclude:

-   2-amino-9-(4-hydroxy-3-hydroxymethylbut-1-yl)purine;-   2-amino-9-(4-acetoxy-3-acetoxymethylbut-1-yl)purine;-   2-amino-9-(4-acetoxy-3-hydroxymethylbut-1-yl)purine;-   2-amino-9-(3-hydroxymethyl-4-methoxycarbonyloxybut-1-yl)purine;-   2-amino-9-[2-(2,2-dimethyl-1,3-dioxan-5-yl)ethyl]purine;-   2-amino-9-(4-propionyloxy-3-propionyloxymethylbut-1-yl)purine;-   2-amino-9-(4-butyryloxy-3-hydroxymethylbut-1-yl)purine;-   2-amino-9-(4-benzoyloxy-3-hydroxymethylbut-1-yl)purine;-   2-amino-9-(4-hydroxy-3-hydroxymethylbut-1-yl)purine 4′-phosphate;    and-   2-amino-9-(4-hydroxy-3-hydroxymethylbut-1-yl)purine 4′:4″phosphate.    Methods for producing pharmaceutically acceptable formulations of    famciclovir and derivatives thereof are described in U.S. Pat. No.    5,246,937, herein incorporated by reference.

In addition, U.S. Pat. No. 5,580,571, incorporated by reference, teachesthat the following nucleoside analogues exhibit enhanced anti-viralactivity as phosphate esters and can be used as active agents:

-   1-beta-D-arabinofuranosyl-E-5-(2-bromovinyl)uracil [broavir;    BV-araU];-   2′-fluorocarbocyclic-2′-deoxyguanosine;-   6′-fluorocarbocyclic-2′-deoxyguanosine;-   1-(beta-D-arabinofuranosyl)-5(E)-(2-iodovinyl)uracil;-   SQ 34,514;-   HOE 602;-   triflurothymidine;-   9-[(1,3-dihydroxy-2-propoxy)methyl]guanine;-   5-ethyl-2′-deoxyuridine;-   E-5-(2-bromovinyl)-2′-deoxyuridine;-   5-(2-chloroethyl)-2′-deoxyuridine;-   1-(2-deoxy-2-fluoro-beta-D-arabinofuranosyl)-5-iodocytosine (FIAC);-   1-(2-deoxy-2-fluoro-beta-D-arabinofuranosyl)-5-iodouridine (FIAU);-   buciclovir;-   6-deoxyacyclovir;-   9-(4-hydroxy-3-hydroxymethylbut-1-yl)guanine;-   E-5-(2-iodovinyl)-2′-deoxyuridine;-   5-vinyl-1-beta-D-arabinofuranosyluracil (V-araU);-   1-beta-D-arabinofuranosulthymine (Ara-T);-   2′-nor-2′deoxyguanosine (2′NDG);-   9-(4-hydroxy-3-hydroxymethylbut-1-yl)guanine (penciclovir, BRL    3912); and-   1-beta-D-arabinofuranosyladenine (Ara-A; vidarabine).

It will be appreciated that each of these nucleoside analogues orderivatives thereof can be an active agent in a systemic composition.The nucleoside analogues can be converted to active forms throughmetabolic pathways. The active agent may thus be any of the above-citednucleoside analogues, other analog, derivative, or metabolite thereof inorder to provide an active form of the active agent.

The active agent is preferably in a state which is able to be mixed witha suitable carrier. Aciclovir, in particular, is poorly soluble inwater, which limits formulation of a topical solution and/or systemictreatments in aqueous carriers. In addition, aciclovir is poorlyabsorbed from the gastrointestinal tract after oral administration andis therefore typically be administered in large doses. Therefore,pharmaceutically acceptable formulations of nucleoside analogues canprovide the drug in a form which is easily absorbed into the bloodstream. A pharmaceutically acceptable salt, phosphate ester or acylderivative of the active agent can be formulated for use as a systemictreatment, optionally with a carrier or excipient (discussed below). Forexample, the nucleoside analogue can be provided in a salt form whichallows it to be more easily soluble in water and/or plasma. In addition,the nucleoside analogue in salt form can be more easily absorbed by thegastrointestinal tract. A pharmaceutically acceptable salt form of theactive agent can thus be prepared using sodium, potassium, ammonium, orhydrogen. In addition, salt forms of active agents can be formed usinghydrochloric acid, sulphuric acid, phosphoric acid, maleic acid, fumaricacid, citric acid, tartaric acid, lactic acid, acetic acid orp-toluenesulphonic acid.

In another embodiment, the active agent could be an agent, other than anucleoside or nucleotide analogue, which impairs the reproductivefunction of the virus through other mechanisms besides imitatingnucleoside or nucleotides essential for replication. For example, theactive agent may prevent the virus from entering the cell, which isvital for virus replication.

The amount of active agent present in the formulation should besufficient to be antivirally effective and be non-toxic. Becausenucleoside analogues, nucleoside analogue precursors, and nucleotideanalogues are known in the art, one or ordinary skill can determine apharmaceutically acceptable dosage of active agent. The desired dose canbe administered as two, three, four or more sub-doses at appropriateintervals throughout the day. These sub-doses may be administered inunit dosage forms, for example, containing 10 to 1000 mg, preferably 20to 500 mg and most preferably 100 to 400 mg of active agent per unitdosage form.

B. Carriers and Therapeutic Components for Systemic Treatment

Suitable methods for delivering the active agent systemically include,but are not limited to, oral and parenteral (including subcutaneous,intramuscular, intravenous, intradermal, intrathecal and epidural). Thepreferred route can vary depending on the condition of the patient. Theamount delivered will depend on the severity of the condition, which canbe determined by the attendant physician.

While it is possible for the active agents to be administered alone, itis preferable to present them as pharmaceutical formulations. Theformulations comprise at least one active agent together with one ormore carriers and optionally other therapeutic components. Preferably,the carrier is compatible with the other components of the formulationand not deleterious to the patient receiving the treatment.

The formulations may conveniently be presented in unit dosage form andmay be prepared by any of the methods well known in the art of pharmacy.Such methods include the step of bringing into association the activeagent with the carrier, which constitutes one or more accessorycomponents. In general, the formulations are prepared by uniformly andintimately bringing into association the active agent with liquidcarriers or finely divided solid carriers or both, and then, ifnecessary, shaping the product.

Formulations of systemic treatments suitable for oral administration maybe presented as discrete units such as capsules, cachets or tablets eachcontaining a predetermined amount of the active agent; as a powder orgranules; as a solution or a suspension in an aqueous liquid or anon-aqueous liquid; or as an oil-in-water liquid emulsion or awater-in-oil liquid emulsion. The active agent may also be presented asa bolus, electuary, paste, gelatin capsule, or syrup. Additionalflavoring or coloring components may optionally be added.

A tablet may be made by compression or molding, optionally with one ormore accessory components. Compressed tablets may be prepared bycompressing in a suitable machine the active agent in a free-flowingform such as a powder or granules, optionally mixed with a binder,lubricant, inert diluent, preservative, surface active or dispersingagent. For example, magnesium stearate, starch, lactose, glucose, rice,flour and chalk may be used to form tablets. Molded tablets may be madeby molding in a suitable machine a mixture of the powdered compoundmoistened with an inert liquid diluent. The tablets may optionally becoated or scored and may be formulated so as to provide slow orcontrolled release of the active agent therein.

Formulations suitable for parenteral administration include aqueous andnon-aqueous sterile injection solutions which may contain anti-oxidants,buffers, bacteriostats and solutes which render the formulation isotonicwith the blood of the intended recipient; and aqueous and non-aqueoussterile suspensions which may include suspending agents and thickeningagents. The formulations may be presented in unit-dose or multi-dosecontainers, for example sealed ampoules and vials, and may be stored ina freeze-dried (lyophilized) condition requiring only the addition ofthe sterile liquid carrier, for example water for injections,immediately prior to use. Extemporaneous injection solutions andsuspensions may be prepared from sterile powders, granules and tabletsof the kind previously described. Formulations for intramuscularadministration are also contemplated.

Additionally, other therapeutic components can be used in combinationwith the active agent. In one embodiment, therapeutic components whichenhance the anti-viral activity of the nucleoside can also be added. Forexample, in one embodiment, a ribonucleotide reductase (RR) inhibitorcan be used on conjunction with acyclovir to provide an enhancedantiviral effect as taught in U.S. Pat. No. 4,758,572, hereinincorporated by reference. In another embodiment, interferon canoptionally be used.

III. Anti-Infective Compositions for Topical Administration

The terms “topical treatment” and “topical administration” refer toadministration of an anti-infective composition to the surface of thedisordered tissue caused by a virus. In general, the anti-infectivecomposition is formulated and/or applied in a manner so that atherapeutically effective amount of anti-infective agent does not enterthe bloodstream of the patient and therefore is not a systemic treatment(only minor, non-therapeutic amounts may be able to enter thebloodstream). Topical treatment includes external application of ananti-infective composition to disordered tissue even if located inside abody cavity (e.g., mouth, anus or vagina). Anti-infective compositionsmay include one or more components comprising active agents, carriersand/or therapeutic components, as will now be described.

According to one embodiment, the active agent included in theanti-infective compositions comprises at least one of an organohalide,docosanol, iodine, nucleoside analogue, or nucleotide analogue in aliquid carrier having a tissue penetrating component. Organohalides,such as quaternary ammonium halides, contain at least one carbon-halogenbond. Benzalkonium chloride is an example organohalide. Otherorganohalides include organo-bromides and organo-iodides. Preferably,the organohalides have an alkyl group attached thereto such as a simpleC_(n)H_(2n+1) chain, where n is in a range from 1 to about 50.

The generic chemical structure of benzalkonium chloride is shown below:

As shown, benzalkonium chloride includes a benzene ring and a nitrogenconstituent (i.e., a quaternary ammonium group) near the ring. A carbonatom is disposed between the nitrogen constituent and the benzene ring.Two methyl groups and an alkyl group of varying size extend from thenitrogen atom.

An example embodiment includes a mixture of compounds with an alkylchain length distribution that is about 40% C₁₂, about 50% C₁₄, andabout 10% C₁₆ (CAS Reg. No. 68424-85-1). Examples include MaquatMC-1412-50%, Mason Chemical Company, 50% activity; Maquat MC-1412-80%,Mason Chemical Company, 80% activity; and BTC-835, Stepan Company, 50%activity. Notwithstanding the fact that “benzalkonium chloride” oftenrefers to mixtures of compounds of varying alkyl chain length, it shouldbe understood that one may utilize a singular benzalkonium chloridecompound comprising only one alkyl chain of a particular length.

These anti-infective agents, particularly benzalkonium chloride, arehighly effective in deactivation of viruses or otherwise limiting thesource of infections and other complications related to disorderedtissue. Also, these anti-infective agents can neutralize or eliminatetoxins and inflammatory agents caused by viruses. Rapidly eliminating orneutralizing toxins, inflammatory agents, and their sources results inprompt pain relief.

Benzalkonium bromide and benzalkonium iodide are additional examples ofsuitable organohalides. Benzalkonium bromide has the structure ofbenzalkonium chloride with the difference being that the chlorine issubstituted with a bromine constituent. Analogous considerations applyto benzalkonium iodide. Another example of a suitable organohalide iscetyl trimethylammonium bromide.

Examples of other organochlorides which have anti-infective propertiesinclude benzethonium chloride, methyl benzethonium chloride, cetylpyridinium chloride, chloroxylenol, hexachlorophene, triclosan, andchlorhexidine. Note that some of the above organochlorides are notsuitable for all purposes. For example, benzethonium chloride,chloroxylenol, and chlorhexidine should not be used in a manner whichwould enable them to be ingested in a toxic quantity. Examples of otherorganohalides which may be suitable, more particularly quaternaryammonium halides having an alkyl with 6-18 carbons, include: alkylbenzyl dimethyl ammonium halide, alkyl dimethyl ethyl benzyl ammoniumhalide, n-alkyl dimethyl benzyl ammonium halide, diisobutyl phenoxyethoxy ethyl dimethyl benzyl ammonium halide, n-(C₁₂C₁₄C₁₆)alkyldimethyl benzyl ammonium halide, dodecyl dimethyl ammonium halide,dioctyl dimethyl ammonium halide, dialkyl dimethyl ammonium halide,dialkyl methyl benzyl ammonium halide, octyl decyl dimethyl ammoniumhalide, lauryl dimethyl benzyl ammonium halide, o-benzyl-p-chlorophenol,dideryl dimethyl ammonium halide, dioctyl dimethyl ammonium halide, andalkyl (C₁₄C₁₂C₁₆)dimethyl benzyl ammonium halide.

Additional examples of effective organohalides include dual quaternaryammonium compounds comprising at least two quaternary ammoniumcompounds, e.g., a mixture of n-alkyl dimethyl benzyl ammonium halideand n-dialkyl methyl benzyl ammonium halide. An example is distributedby Stepan as BTC7 776, with a chain length distribution for the n-alkylof about 60% C₁₄, about 30% C₁₆, about 5% C₁₂, and about 5% C₁₈ (CASReg. No. 683991-10-5), and a chain length distribution for the n-dialkylof about 60% C₁₄, about 30% C₁₆, about 5% C₁₂, and about 5% C₁₈ (CASReg. No. 68391-05-9). Another example comprises a mixture of n-alkyldimethyl benzyl ammonium halide (I) and n-alkyl dimethyl ethyl benzylammonium halide (II). An example is distributed by Stepan as BTC 21257Mseries with a chain length distribution for the n-alkyl in entity (I) ofabout 60% C₁₄, about 30% C₁₆, about 5% C₁₂, and about 5% C₁₈ (CAS Reg.No. 683991-10-5), and a chain length distribution in entity (II) ofabout 68% C₁₂, and about 32% C₁₄ (CAS Reg. No. 68956-79-6).

The liquid carrier preferably has properties that enhance the ability ofthe treatment composition to penetrate into the disordered epithelialtissue. The carrier may have a viscosity and/or density which is notsignificantly greater than that of water in order to optimally enablethe treatment composition to penetrate into the disordered tissue. Usinga carrier composition having a viscosity which is not significantlygreater than water is in contrast to compositions that are coated ontoafflicted tissue. Accordingly, treatment compositions according to someembodiments exclude formulations which may be considered to be primarilyor essentially gels, creams, lotions, oils, ointments, pastes,emulsions, and viscous colloidal suspensions. Alternatively, topicalcompositions can also include formulations which may be considered to beprimarily or essentially gels, creams, lotions, oils, ointments, pastes,emulsions, and colloidal suspensions. In addition, small amounts ofinert abrasive material may be present in the topical compositions.

Although, water alone may be used as the carrier, it is not preferredbecause other compounds, such as some alcohols, have a tissuepenetrating capability that water lacks. The carrier in the topicalcomposition is also preferably not formed entirely from an alcohol suchas isopropyl alcohol or ethyl alcohol, since their use may be morepainful in some circumstances. When an open sore is part of thedisordered tissue, the amount of alcohol or other composition that has asignificant tissue penetrating ability may be modified by adding waterso as to moderate the amount of discomfort that the patient experiencesby the application of the composition to the open sore. Additionally,alcohols such as isopropyl alcohol rapidly evaporate. Further, it may bepreferred to use alcohols such as isopropyl alcohol with otherconstituents such as water due to regulatory issues. Suitable alcoholsinclude, but are not limited to, ethanol, methanol, benzyl alcohol,cetyl alcohol,

Other compounds that are preferred as carriers include acetic compoundssuch as acetone, acetic acid, acetic anhydride, and the like. While someacetic compounds may not be as effective as some alcohols, acetoneexhibits an effective ability to penetrate tissue. In anotherembodiment, the carrier may include a mixture of water, alcohol, andacetone. U.S. Pat. No. 6,211,243, hereby incorporated by reference,describes suitable concentrations of water and alcohol mixtures andcarriers including acetic compounds.

The carrier preferably has a tissue penetrating component, such asisopropyl alcohol, that is capable of penetrating the skin and cells ina rapid manner without rapidly diffusing beyond the skin and into thebloodstream. The treatment composition enables the stratum spinosum ofskin to be saturated in the region of the cold sore or other disorderedtissue for a period that enables the treatment composition to achieveits purpose before it diffuses into the body. In this way, the treatmentcomposition forms a temporary reservoir (or bath) in the region where itis needed most. In this way, the treatment composition can maximize itseffect of deactivating viruses within the disordered tissue whileminimizing possible damage to surrounding healthy tissues or theorganism as a whole.

While isopropyl alcohol is a preferred carrier, other alcohols may alsobe used. In addition to isopropyl alcohol, ethanol and methanol are alsosuitable carriers. Benzyl alcohol can be used as a carrier or as anadditive as it also acts as a bacteriostat and an anesthetic. Acetonecan also be used. Mixtures of the above-mentioned solvents may also beused as desired depending upon the application. As indicated above,however, isopropyl alcohol or ethyl alcohol is preferably used incombination with other carrier constituents. For example, as mentionedabove, water may be added to isopropyl alcohol to reduce the pain whichmay be felt when only isopropyl alcohol is used. Similarly, isopropylalcohol may be utilized with cetyl alcohol or a combination of cetyl,stearyl, myristyl, or lauryl alcohol and water to reduce pain. Examplesof dermal penetration enhancers include dimethylsulphoxide (DMSO) andrelated analogues.

Carriers that include isopropyl alcohol and water can have varyingratios depending on the intended use. However, for treating colds sores,water is preferably included in a range from about 10% to about 50% byvolume of the carrier, with the remainder being isopropyl alcohol. Thewater content is more preferably in a range from about 20% to about 40%by volume of the carrier, and most preferably about 30% by volume of thecarrier and wherein the isopropyl alcohol is included in an amount ofabout 70%. Embodiments of preparations according to the presentinvention may include a carrier that comprises an alcohol, preferablyisopropyl alcohol, at a concentration in a range from about 20% to about90% by volume, preferably in a range from about 40% to about 85% byvolume, and more preferably in a range from about 50% to about 80% byvolume. The carrier may also include other solvents such as acetone, andthe like.

A preferred method of preparing an example treatment compositioninvolves taking 70% isopropyl rubbing alcohol USP (70% isopropanol, v/v,specific gravity 0.877 at 20 C, see 35 USP, p. 357) and then admixingthe benzalkonium halide, NF. Isopropyl alcohol USP (IPA) is availablefrom any number of US sources, including Union Carbide, AldrichChemical, Texaco, and Shell. Purified water USP is available from avariety of laboratory supply houses, such as Aldrich Chemical, FisherScientific, and VWR Scientific. Purified water USP can also be obtainedby means of a commercially available water purification system designedto meet the requirements of Purified Water USP.

Embodiments include preparations with organohalide concentrations in therange from about 0.001% to about 2% by weight of the anti-infectivecomposition. When the anti-infective agent is benzalkonium chloride orother aromatic quaternary ammonium halide compound, the concentrationwithin a topical composition is preferably in a range from about 0.01%and to about 0.5% by weight, more preferably in a range from about 0.05%to about 0.3% by weight, and most preferably in a range from about 0.1%to about 0.2% by weight. To avoid toxicity, the concentration can beless than 0.26% by weight and is more preferably about 0.13% by weight.

An important issue when applying the treatment composition to a painfulcold sore, shingles, or other disordered tissue is proper compliance bythe user. Solvent carriers, such as isopropyl alcohol, ethanol,methanol, acetone, and the like, can cause excruciating pain whenapplied to sensitive disordered tissues such as cold sores and shingles.Such pain can discourage compliance by the user and undermine theeffectiveness of an otherwise effective treatment composition. Thetreatment composition may therefore also include benzocaine or othertopical anesthetic, which can promote compliance by reducing pain and,in some cases, can even enhance penetration of the composition into thedisordered tissue.

Unexpectedly, benzocaine or other topical anesthetics, when included inspecific amounts, can increase the ability of such treatmentcompositions to penetrate into the disordered tissue in order for theactive agent to more quickly contact and deactivate viruses or otherpathogens within the disordered tissue. Benzocaine or other topicalanesthetics can also increase patient compliance by reducing the painassociated with application of the anti-infective composition to painfuldisordered tissue, particularly with open sores. However, beyond merelyreducing pain, benzocaine or other topical anesthetics have been foundto increase efficacy of treatment because they promotes fasterpenetration of the treatment composition into disordered tissue, whichreduces the amount of rubbing or agitation that would otherwise berequired for the composition to be effective.

The amount of benzocaine or other topical anesthetic within thetreatment composition is high enough to enhance penetration, andpreferably help alleviate pain. However, the amount of benzocaine orother topical anesthetic is advantageously not so high as to leave aresidue on the surface of the skin and/or cause loss of sensation insurrounding tissue and/or for a prolonged period of time (e.g., greaterthan about 15 minutes). For example, if included in excessive amounts,benzocaine or other topical anesthetic can cause numbing of asubstantial portion of a person's lips for an extended period of time,which can inhibit normal activities such as drinking and talking (e.g.,as can occur after a person leaves a dental office after receiving aninjection of novocaine).

The amount of benzocaine or other topical anesthetic is most effectivewhen numbing is temporary and goes away once the treatment compositionhas effectively penetrated into the disordered tissue and resided longenough in the disordered tissue to deactivate the pathogens andneutralize inflammatory agents in the tissue causing the pain. Accordingto one embodiment, the amount of benzocaine or other topical anestheticis selected to provide a numbing effect for a time period of about 1minute to about 20 minutes, preferably about 2 minutes to about 15minutes, more preferable about 3 minutes to about 10 minutes, and mostpreferably about 4 minutes to about 8 minutes after numbing firstoccurs. It is desirable to include an amount of benzocaine or othertopical anesthetic so that numbing begins in about 10 seconds or lessafter application of the treatment composition, preferably in about 8seconds or less, more preferably in about 6 seconds or less, and mostpreferably in about 4 seconds or less.

The highly penetrating compositions are formulated so as to penetratequickly so that the treatment composition is no longer detected on theskin surface after less than about 1 minute, preferably less than about40 seconds, more preferably less than about 20 seconds, and mostpreferably less than about 10 seconds. Viruses are deactivated andinflammatory agents are neutralized within minutes or seconds aftereffective penetration such that it is desirable for the numbing effectof benzocaine or other topical anesthetic to subside in less than about10 minutes after application, preferably less than about 8 minutes, morepreferably less than about 6 minutes, and most preferably less thanabout 5 minutes.

After extensive comparative survey testing, it was determined that themost effective amount of benzocaine within treatment compositions thatalso included a liquid carrier comprised of 70% by volume isopropylalcohol in water and 0.13% by weight benzalkonium chloride was betweenabout 2.5% and about 7.5% by weight. Above 7.5%, a benzocaine residuewas sometimes detected. Below about 2%, benzocaine did not significantlyenhance penetration. Between about 2.5% to about 7.5%, however,benzocaine enhanced penetration and caused temporary, but not excessive,numbing when using the treatment compositions that were tested. A moreoptimal range for this anti-infective composition is about 2.75% toabout 6% benzocaine by weight, and the most optimal range was found tobe about 3% to about 5% benzocaine by weight.

Although less preferred and not as effective as benzocaine in enhancingpenetration of penetrating treatment compositions and/or reducing painwithout causing undue numbing of a user's lip, other topical anestheticsmay be useful in enhancing patient compliance by reducing painassociated with applying penetrating treatment compositions todisordered tissue. Examples of other topical anesthetics that may beused in addition to or instead of include butamben, dibucaine,lidocaine, oxybuprocaine, pramoxine, proparacaine, proxymetacaine,prilocaine, tetracaine, novocaine, bupivocaine, carbocaine, ropivocaine,xylocaine, cocaine, and mixtures thereof. Of the foregoing, butamben mayperform most similar to benzocaine given the similarity in the twochemical structures. Other anesthetics include caffeine, nicotine, oilof clove, tea tree oil (melaleuca alternifolia, which also acts as adisinfectant), tronothane, dyclonine, dyclonine hydrochloride, pramoxinehydrochloride, diperodon, butamben picrate, cyclomethycaine sulfate,cyclomethycaine hydrochloride, dimethisoquin hydrochloride, and phenol.

Such other topical anesthetics can be included in amounts similar tothose of benzocaine. Alternatively, they can be included in an amountbetween 2.1% and about 15% by weight of the treatment composition, orbetween about 2.2% and about 10% by weight, or between about 2.3% toabout 8% by weight, or between about 2.5% to about 6% by weight. Suchother topical anesthetic, either alone or if combined with anothertopical anesthetic, such as benzocaine, may be included in an amount soas to numb the treatment area for a time period of about 1 minute toabout 20 minutes, preferably about 2 minutes to about 15 minutes, morepreferably about 3 minutes to about 10 minutes, and most preferablyabout 4 minutes to about 8 minutes after numbing first occurs. It isdesirable to include an amount of topical anesthetic so that numbingbegins in about 10 seconds or less after application of the treatmentcomposition, preferably in about 8 seconds or less, more preferable inabout 6 seconds or less, and most preferably in about 4 seconds or less.

The carrier may also include other components that, by themselves, maybe too viscous to act as tissue penetrating agents, but which, incombination with water, isopropyl alcohol, and other solvents identifiedherein or known to those of skill in the art, can penetrate tissue. Suchcomponents include ethoxylated alcohols (e.g., lauryl alcoholethoxylates), ethoxylated nonylphenols (e.g., Nonoxynol-9), lowmolecular weight glycols (e.g., ranging from ethylene glycol to PEG-400,propylene glycol, propanediol, and the like), ethoxylated amines, andtheir quaternaries. Certain essential oils and emollients, which arenormally water insoluble, can be made soluble in water by ethoxylation(e.g., ethoxylated lanolin).

Penetration inhibiting components include chemicals which are petrolatumbased substances, materials conventionally utilized as thickeners,naturally occurring oils, substances derived from naturally occurringoils, or any other substance which is added primarily to increase thetendency of a treatment composition to remain on the surface ofdisordered tissue such as a cold sore. The term “substantially oil-free”means that oil substances are may be present in an amount of less thanabout 2% by volume, preferably less than about 1%, more preferably lessthan about 0.05%, and most preferably less than about 0.01%.

Treatment compositions may include other components that achieve aparticular result and do not substantially reduce the ability of thetreatment composition to penetrate into the disordered tissue or theability of the treatment composition to be anti-infective. Examples ofsuch components include pH adjusters, substances having anestheticqualities, vasodilators, analgesics and defoamers. Example pH adjustorsmay include organic acids, mineral acids in minute amounts, organicbases or mineral bases also in minute amounts. Example organic acidsinclude citric acid, ascorbic acid, sorbic acid, malic acid, asceticacid, succinic acid, caproic acid, and the like. Other acids includehydrochloric acid, nitric acid, hydroiodic acid, and the like in minuteamounts. Example bases include methyl and ethylamines such astriethanolamine, and the like. Other bases include, ammonium hydroxide,potassium hydroxide, sodium hydroxide, and the like.

Preservatives may be added to the anti-infective composition, includingparabens, preferably methyl and propyl parabens. Preservatives, ifpresent, are included in the composition in a range from about 0.0001%to about 0.01% by volume of the treatment composition.

The active agent can also include a nucleoside analogue, nucleosideanalogue precursor, nucleotide analogue, or any other anti-viral drugdiscussed above relative to systemic treatment. Because nucleosideanalogues are discussed above in great detail with regard to systemictreatments, they will not be discussed again except to note that thenucleoside analogue should generally be delivered in an active form ifused in a topical composition. The active agent may thus be any of theabove-cited nucleoside analogues, derivative, or metabolite thereof inorder to provide an active form of the active agent. In one embodiment,the same anti-virus drug used in the systemic composition can also beused in a topical composition. Alternatively, a different anti-virusdrug can be used.

Topical formulations incorporating an anti-virus drug as active agent,including analogs, metabolites, or derivatives thereof, can include theactive agent in an amount of, for example, about 0.01% to about 50% w/w;preferably from about 0.1% to 25% w/w; most preferably from about 1% toabout 15% w/w. Other topical formulations incorporating an anti-virusdrug may include the active agent in an amount of, for example, fromabout 0.075% to about 20% w/w, preferably from about 0.2% to about 15%w/w and most preferably from about 0.5% to about 10% w/w.

The active agent could also be another compound that acts to reduce orinhibit viral replication other than by substituting as a nucleotide. Inone embodiment, a non-nucleoside includes docosanol or behenyl alcohol(sold under the trademark Abreva™). Docosanol is a 22 carbon straightchain-saturated alcohol. N-docosanol is claimed to inhibit fusionbetween the plasma membrane and the viral envelope. This prevents viralentry into the cell and, as a result, reduces or disrupts viralreplication. When present in a topical formulation, docosonal can bepresent in a volume range from about 5% to about 15%.

In one embodiment, a nucleoside (e.g., aciclovir) can be formulated asan oil-in-water topical formulation in which the oil is dispersed in anaqueous phase and most of the nucleoside is located in the aqueous phasewhich, in one embodiment, can comprise water and polyhydric alcohol. Apolyhydric alcohol is an alcohol having two or more hydroxyl groups.Polyhydric alcohols suitable for incorporation into topical formulationsinclude glycols and macrogols such as propylene glycol, butane 1,3-diol,polyethylene glycol, glycerol, mannitol, sorbitol, and mixtures thereof.The oil phase or emulsifying wax of the oil-in-water formulation caninclude a hydrophilic emulsifier (otherwise known as an emulgent) anddesirably at least one lipophilic emulsifier such as fat or oil or bothto act as a stabilizer. Further details describing how to formulate anoil-in-water topical formulation are contained in U.S. Pat. No.4,963,555, hereby incorporated by reference.

Other components for the topical compositions include vasodilators suchas nitroglycerine and the like. Vasodilators are useful for causingpenetration of the active agent or agents into the disordered tissue toits base in the skin or mucous membranes and beyond. Care must be takento balance the effect of localized vasodilation against the systemictoxicity of the topical composition such that penetration into thedisordered tissue is clinically significant, but that the active agentor agents remain substantially local to the disordered tissue formaximum efficacy. Where a vasodilator is supplied to make up the topicalcomposition, it may be provided in a preferred range from about 0.001%to about 0.05% by volume of the topical composition.

Other components for the topical composition include analgesics such asmethyl salicylate, aspirin, and other salicylate salts. Other componentsfor their analgesic effects include N,N-dimethyl aspartic acid;N—N-dimethyl glutamic acid, trolamine salicylate, antipyrine, andsalicylamide. Where an analgesic is present, it may be supplied to makeup the composition in a preferred range from about 0.001% to about 0.01%by volume of the topical composition.

For infections of the eye or other external tissues, e.g., mouth andskin, the formulations are preferably applied as a topical solution,ointment or cream containing the active agent in an effective amount of,for example, 0.075 to 20% w/w, preferably 0.2 to 15% w/w and mostpreferably 0.5 to 10% w/w. When formulated in an ointment, the activeagents may be employed with either paraffinic or a water-miscibleointment base. Alternatively, the active agents may be formulated in acream with an oil-in-water cream base. In addition topical applicationsmay be made transdermally by means of an iontophoretic device.

Formulations suitable for topical administration to the eye also includeeye drops wherein the active agent is dissolved or suspended in asuitable carrier, especially an aqueous solvent for the active agent.The active agent is preferably present in such formulations in aconcentration of about 0.5% to about 20%, advantageously about 0.5% toabout 10%, and even more preferred about 1.5% w/w.

Formulations suitable for topical administration in the mouth includelozenges comprising the active agent in a flavored basis, usuallysucrose and acacia or tragacanth; pastilles comprising the active agentin an inert basis such as gelatin and glycerine, or sucrose and acacia;and mouthwashes comprising the active agent in a suitable liquidcarrier.

Formulations suitable for nasal administration wherein the carrier is asolid include a coarse powder having a particle size for example in therange 20 to 500 microns which is administered by rapid inhalationthrough the nasal passage from a container of powder held close up tothe nose. Suitable formulations wherein the carrier is a liquid, foradministration as for example a nasal spray or as nasal drops, includeaqueous or oily solutions of the active agent.

Formulations suitable for vaginal administration may be presented aspessaries, tampons, creams, gels, pastes, vaginal suppositories, foamsor spray formulations containing in addition to the active agent suchcarriers as are known in the art to be appropriate. Formulations forrectal administration may be presented as a suppository with a suitablebase comprising for example cocoa butter or a salicylate or may be apaste or cream applied into the anus via an applicator (“pile pipe”).

The topical compositions can be applied to various parts of a personsbody in a variety of ways. In one embodiment, the topical composition isapplied using a person's hand or finger. In another embodiment, anapplicator is used. An applicator can be beneficial to prevent oils,bacteria, or other contamination from a person's hands to contact theinfected site in order to prevent further opportunistic infection of thevulnerable area. If an applicator is used, preferably, the applicator issterile.

Applicators may form part of a method and system for applying thetreatment compositions. As such, applicators may be preconfigured withparticular mixtures to treat specific disorders, such as cold sores,chickenpox, herpes zoster (shingles), genital herpes, and the like.Examples of applicators include those taught in U.S. Pat. No. 6,211,243(Johnson), U.S. Pat. No. 5,709,866 (Booras et al.), U.S. Pat. No.5,704,906 (Fox), U.S. Pat. No. 5,527,534 (Mythling), U.S. Pat. No.5,016,651 (Stalcup et al.), U.S. Pat. No. 4,887,994 (Bedford), and U.S.Pat. No. 4,952,204 (Korteweg), the disclosures of which are incorporatedherein by reference. Example applicators include prepackaged applicatorswith agitation pads impregnated with the treatment composition. Anapplicator may be provided as a unitary structure such as a sealedcontainer that is frangible and configured for a single use.

A method of topically administering the anti-infective compositionincludes impregnating an applicator with the topical composition andcontacting the treatment site with the applicator. Agitation and/orcompression of the disordered tissue may be useful to enhancepenetration of the composition. It may also stimulate the immune systemby causing trauma to the disordered tissue.

IV. Combination of Systemic and Topical Treatments

Combining systemic treatment of disordered tissue caused by a virususing a pharmaceutically acceptable quantity of anti-virus drug withtopical administration of an anti-infective composition to thedisordered tissues results in greater efficacy of treatment. Even thoughtopical administration of an anti-infective composition is notrecognized by the FDA or scientific community as being therapeuticallyeffective to systemically eradicate viruses that cause disorderedtissues, it has now been found that topically administering ananti-infective composition to disordered tissue while systemicallyadministering an anti-virus drug unexpectedly results in greatersystemic treatment of the virus. In other words, a topical treatmentthat is itself non-systemic in nature unexpectedly exhibits a systemictreatment effect when used in combination with a systemicallyadministered anti-virus drug. The systemic treatment effect is exhibitedby a reduction in the amount of time and/or number of dosages requiredby the systemically administered anti-virus drug to otherwisesystemically treat the disease by itself, in the absence of topicaltreatment with an anti-infective composition.

One explanation for this phenomenon, postulated by the inventor, is thatviruses that cause disordered tissues to erupt on mammalian skin becomelocally concentrated at the disordered tissue site. This makes suchviruses more difficult to treat using systemically administeredanti-virus drugs, which may not easily penetrate through the stratumbasal layer to the epidermis. Instead, such viruses are more easilydeactivated using a topically administered anti-infective compositionthat can penetrate through the outer layer of skin and attack theviruses at the disordered tissue site. It is postulated thatdeactivation of such viruses at the disordered tissue site using apenetrating anti-infective topical composition reduces the overallnumber of viruses in the patient's body that must be treated by thesystemic drug, thereby significantly reducing the amount of time and/ordosages of systemic drug that would otherwise be required to treat theoutbreak using the systemic drug by itself. In addition, it ispostulated that, to the extent the stratum basal layer inhibits systemicmedication from passing through to the epidermis, topically treating anddeactivating viruses at the disordered tissue site may be more effectivethan deactivating such viruses using the systemic treatment. The resultis synergistic dual treatment of the disease by the systemic drug, whichis effective in treating viruses internally but less effective at theskin surface, coupled with topical treatment of the disordered tissueusing a penetrating anti-infective composition, which is effective indeactivation of viruses near the skin surface but not internally beyondthe disordered tissue site.

Co-administration of a systemic anti-viral drug and a topicallyadministered penetrating anti-infective composition has also been foundto reduce or eliminate post-herpetic neuralgia, which is caused by nervedamage. This is unexpected since systemic anti-viral drugs on their owncan often resolve the acute symptoms associated with disordered tissuesyet not prevent nerve damage and/or chronic neuralgia, which is anextremely painful neurological condition for which there is no knowncure.

Post-Herpetic Neuralgia (PHN) is a complication arising in some cases ofherpes zoster (shingles). It can involve very sharp pains long aftervisible signs and symptoms of shingles have abated. It can last days,weeks, months, years, or decades. The risk of PHN is the principalreason that some physicians prescribe anti-depressants. PHN has been afactor in elderly suicide. It is important to understand that noteveryone who gets singles also gets post-herpetic neuralgia. However,there are several factors that influence PHN. The older the patient, thegreater the chance of PHN. The longer one has visible signs andsymptoms, the greater the risk of PHN. And, whether or not the patientwas previously vaccinated will affect the chances, duration, andseverity of PHN. Likewise, timely dosing with nucleoside analogue drugs(within the first 72 hours of first signs and symptoms) can reduce therisk of and/or the severity of PHN, but it will not eliminate the riskof PHN. Thus, combining systemic and topical treatments of disorderedtissues caused by viruses, such as the herpes zoster virus, has asynergistic effect that is not expected and which is not demonstratedwhy either treatment is performed separately.

Example methods of dual treatment include systemically administering oneor more dosages of a pharmaceutically acceptable amount of one or moreanti-virus drugs as disclosed herein. The amount and timing of systemicadministration of one or more anti-virus drugs can be the same as thosefollowed according to standard treatment protocols. For example, whenusing anti-virus drugs such as acyclovir, penciclovir (sold under thetrademark Denavir®), famciclovir (sold under the trademark Famvir®),idoxuridine, ganciclovir (sold under the trademark Cytovene®), cidofovir(sold under the trademark Vistide®), and/or valaciclovir, the dosagesand timing of administrating can be substantially identical or similarto those recommended by the manufacturer and/or as typically prescribedby doctors. An important difference, however, is that the overalltreatment time and/or number of dosages when using such anti-virus drugscan be reduced when such drugs are co-administered together with topicaladministration of one or more anti-infective compositions as disclosedherein to the disordered tissue site.

Administration of the anti-infective composition can be as is disclosedherein and/or as described in any of U.S. Pat. Nos. 6,211,243,6,410,599, 6,414,032, 6,423,750, 6,759,434, 8,173,709, and 8,217,080(all to Johnson), herein incorporated by reference. In its simplestform, the anti-infective composition is applied using an appropriateapplicator device and/or using the person's or healthcare professional'shand or finger in order to cause or allow the anti-infective compositionto penetrate sufficiently into the disordered tissue in order to killviruses at the disordered tissue site.

FIG. 1 depicts a vertical cross-section of the epidermis and thepapillae of the dermis. The stratum corneum 28 is disposed upon thefatty layer or stratum lucidum 30. The stratum lucidum is disposed overthe stratum granulosum 32. Below the stratum granulosum 32 is thestratum spinosum 34. Typically, the stratum spinosum 34 has a lipid filmdisposed around each individual cell. Below the stratum spinosum 34 isthe stratum basale 38 that overlies vascularized tissue. Within thevascularized tissue the nervous papilla of the corium 36 is locatedalong with blood vessels and nerves 40. It is postulated that, during aviral outbreak that causes painful disordered to tissue to form on aperson's skin, a disproportionate number of disease-causing viruses areconcentrated at or near the the nervous papilla of the corium 36,surrounding vascularized tissue, and stratum spinosum 34. Because ofthis, systemic treatment using system anti-virus drugs may be lesseffective in treating viruses at the disordered tissue site, since thedrug may have difficulty penetrating the stratum basal layer 38.

During application of the topical anti-infective composition, anapplicator 12 saturated with penetrating anti-infective composition 22can be used. To further enhance penetration of anti-infectivecomposition 22 into the various layers of tissue in order to reach theviruses, the applicator 12 can be vigorously agitated across the stratumcorneum 28 in order to cause or allow anti-infective composition 22 topenetrate therethrough. The arrows illustrate exemplary agitationmovement. Application of pressure may be as effective, or even moreeffective, than agitation in order to cause or allow penetration ofanti-infective composition 22 through the various layers and to theviruses. It is postulated that anti-infective composition 22 may movethrough the stratum corneum 28 without significant rupture thereof dueto the vigorous agitation thereon. Application of pressure may furtherincrease the ability of composition 22 to penetrate as pressure mayflatten or compress the layers and assist in forcing composition 22downward through the layers. Anti-infective composition 22 can penetrateto the nervous papilla of the corium 36 by the combination of vigorousagitation, pressure and/or the penetrating nature of the composition.Composition 22 may reside in reservoir amounts within the stratumspinosum 34 and may diffuse over time across the stratum basale 38 tothe nerve endings.

The length of time that the anti-infective composition is applied to thedisordered tissue, such as by vigorous agitation and/or pressure, mayvary according to the individual, the size of the applicator surface inrelation to the size of the disordered tissue being treated, the amountof pressure applied and oscillation rate of rubbing. Typically,application of the composition can be maintained for at least 1 secondand is more typically maintained for a period of time in a range fromabout 3 seconds to about 1 minute, or about 5 seconds to about 15seconds.

Dual systemic and topical treatment of disordered tissue means that thesystemic anti-virus drug and topically administered anti-infectivecomposition are applied in roughly the same time frame. For example, thesystemic and topical treatments can be administered within 1 hour ofeach other (e.g., simultaneously, or within 30 minutes, 15 minutes, 10minutes, 5 minutes, or 1 minute of each other). In another embodiment,the systemic and topical treatments can be administered within 12 hoursof each other. In another embodiment, the systemic and topicaltreatments can be administered within 24 hours of each other. In stillanother embodiment, the systemic and topical treatments can beadministered within 2 days of each other.

Such combined use of systemic and topical compositions providessynergistic results in eliminating an infectious virus. First, it ispostulated that the systemic and topical compositions act simultaneouslyon both sides of the stratum basale layer 38 (FIG. 1) of the epidermisto eliminate the infectious virus. While employing only one of eithersystemic or topical treatment, as is typical in the art of treating coldsores, shingles or other disordered tissue, the infectious virus is leftto multiply on at least one side of the stratum basale layer of theepidermis. This results in less effective elimination of the infectiousvirus. It also makes reinfection more likely.

V. Examples

Following are examples of compositions and kits that can be used tocarry out the inventive methods as well as comparative examples oftreatments using only systemic anti-viral drugs to treat herpes relateddisordered tissues.

Comparative Examples 1-3

The following are examples of known regimens for treating Herpes Zoster(shingles) using systemic anti-viral drugs (source:http://www.aafp.org/afp/2000/0415/p2437.html. Stankus, et al.,Management of Herpes Zoster (Shingles) and Postherpetic Neuralgia, AmFam Physician. 2000 Apr. 15; 61(8):2437-2444).

Comparative Average Cost* Example Drug Dosage (in 2000) 1 Acyclovir 800mg orally five times daily for 7 to 10 $174 to 248 (Zovirax)† days; 10mg per kg IV every 8 hours for 7 to 10 days‡ 2 Famciclovir 500 mg orallythree times daily for 7 days $140 (Famvir)† 3 Valacyclovir 1,000 mgorally three times daily for 7 days  $84 (Valtrex)† IV = intravenously.*Estimated cost to the pharmacist based on average wholesale prices(rounded to the nearest dollar), for seven days of therapy, in Red book.Montvale, N.J.: Medical Economics Data, 2000. Cost to the patient willbe higher, depending on prescription filling fee. †Antiviral therapy hasbeen shown to be beneficial only when patients are treated within 72hours of onset of the herpes zoster rash. Antiviral agents are not usedin combination, and selection of an agent is based on dosage scheduleand cost. ‡Acyclovir can be administered IV to severelyimmunocompromised patients or patients who are unable to takemedications orally.

When using any one of the foregoing systemic anti-viral drugs used totreat shingles and other viral tissue disorders, one of ordinary skillin the art would assume that they work as expected to slow or inhibitreplication of the virus within the patient's body even if the outwardsymptom of painful lesions and disordered tissue do not immediatelyresolve. The fact that doctors continue to prescribe the medications inthese example and similar anti-viral medications for treatment ofvarious herpetic tissue disorder outbreaks means they are considered tobe the standard of care and are safe and effective in treating suchdisorders.

In the following examples, both systemic and topical treatments wereused to treat disordered tissue outbreaks. The topically administeredanti-infective compositions were demonstrably able to provide immediaterelief from the outward symptoms of the disordered tissue, both in termsof relieving pain caused by disordered tissue lesions and also causingfaster healing of the disordered tissue lesions. Nevertheless, becausethe use of systemic anti-viral drugs continues to be the standard ofcare for treating such ailments, one of ordinary skill in the art wouldexpect that administering the systemic anti-viral drug would beeffective in treating the long-term effects of the disordered tissueoutbreak. The fact that co-administration of a topical anti-infectivecomposition not only provided faster outward relief of the symptoms ofdisordered tissue but also shortened the duration of overall healing andreduced both short-term pain and post-herpetic neuralgia moreeffectively than administering a systemic anti-viral drug by itself wassurprising and unexpected. This demonstrates the synergistic benefitsobtained by combining systemic and topical treatments of viraldisordered tissues, such as herpes zoster (shingles) and other herpeticdiseases.

Example 4

A female, age 45, with a clinical history of recurrent Herpes Zoster(HZV) (or in layman's terms, shingles) experienced a recurrent outbreakafter a stressful week at work and a weekend in the sun following a tripto a tanning booth. (It is known that stress and UV-B can both triggerherpetic outbreaks.) This subject had her first episode with HZV aboutone year prior. She was diagnosed by her physician and given aprescription for Zovirax (acyclovir). She took the Zovirax, butexperienced lesions lasting 3-4 weeks and experienced over 12 weeks ofpost-herpetic neuralgia. The previous episode included all the classicstages, including weeping, but only involved several very small lesions.

The subject then became aware of preliminary studies combining the useof systemic drugs such as acyclovir and a topically administeredanti-infective composition within the scope of the disclosure. Thetopically administered anti-infective composition (Viroxyn®Professional, used to treat cold sores) was an isopropyl alcoholtincture of benzalkonium chloride, 0.13%, and 7.5% benzocaine.

The recurrence of shingles that was treated with a combination ofacyclovir and Viroxyn® Professional was in the beginning of the thirdday and had progressed from prodromal “tingle”, through papule (raisedbump), to vesicle. By this time some of the vesicles had ulcerated,perhaps as a result of inadvertent scratching of the lesions by thepatient despite her best efforts not to scratch them. There was also a“rash like” appearance near the ulcerated lesions that is typical ofherpes zoster. At the time of treatment, she reported intense pain andsome itching. She reported that the pain was local to the lesion site,but her overall discomfort had made it difficult to sleep the nightbefore. The lesions were located in the chest area and coveredapproximately ¼ of the upper chest area, spreading up onto theshoulders. They varied in size from the smallest, which was about 3×5mm, to the largest, which was a series that had joined confluent to forma lesion area of about 18×25 mm. The subject reported that this was theworst episode of HZV she had ever experienced in all aspects. It was themost painful, covered the largest area, and was the most bothersome.

Prior to treatment at 10:00 am, the lesions and rash were consistentwith herpes zoster lesions, but epithelial damage was still limited,probably due to the early stage of the disease progression. Due to theextensive area covered by the lesions, approximately 30 vials of singledose Viroxyn® Professional cold sore medication were needed to treat allthe lesion sites and rash. In addition to taking acyclovir, the Viroxyn®Professional solution was rubbed onto each sore site in accordance withthe recommended directions for treatment of Herpes Labialis (i.e., coldsores). Following treatment, the area was vigorously washed using bulkViroxyn® Professional solution.

The subject reported a gradual loss of pain, itching, and burning duringthe day of treatment with Viroxyn® Professional. She had no trouble withsleep that night. The next day, all pain, itching, and burning hadsubsided and the lesions were beginning to scab. Four (4) days followingtreatment, all but a few small scabs had fallen off. No other symptomswere present at the time of this report, which was 16 days followingtreatment. There were no adverse events. This example demonstrates thegreatly enhanced and synergistic benefits of combining systemictreatment using an anti-viral drug with topical administration of apenetrating anti-infective composition to disordered tissue caused byherpes zoster.

Example 5

An 83 year old retired physician phoned Quadex (the manufacturer ofViroxyn® Professional) to dictate her own case history. She was livingin an assisted living center when she developed signs and symptoms ofherpes zoster (shingles). She did not immediately identify these signsand symptoms and instead thought that they were a mild skin irritation.By the time she realized that she did indeed have shingles, the 72-hourwindow of effective treatment potential with nucleosides was dangerouslyclose to expiring.

She prescribed valacyclovir (Valtrex) for herself and requested a rideto the pharmacy. While waiting, she remembered that her dentist hadgiven her a sample 3-pack of Viroxyn® Professional to treat heroccasional bouts with herpes labialis (cold sores). While she did notexpect that the anti-viral ingredient would be able to treat hershingles, she wanted to take advantage of the benzocaine for temporaryrelief of the discomfort.

When she phoned in her case report, she reported that she had beenastounded when after less than one hour, and well after the topicalanesthetic effect of the benzocaine had worn off, her physicaldiscomfort began to abate and was fully resolved within one-half day.Within 24 hours the rash and papule like symptoms of shingles had begunto fade and she was completely normal in appearance within 48 hours andexperienced no post-herpetic neuralgia. Topical treatment of thedisordered tissue site with a penetrating anti-infective agent greatlyshortened the time to recovery that otherwise would have been requiredhad the patient taken Valtrex by itself.

Example 6

A 62 year old female was vacationing in California when she developed ared rash and subsequent lesions on her right buttock. She was diagnosedwith herpes zoster (shingles) on day 2 after first signs and symptomsand were noted and was prescribed valacyclovir (Valtrex) per label.However, the Valtrex showed little noticeable effect initially.

On day 18 after first signs and symptoms, and after having completed aValtrex regimen as prescribed by a physician, she still had openherpetic lesions and was in so much pain that she found it difficult tosleep and impossible to sit. As flying was the only way to get to herhome from California, she and her husband elected to extend their timein California.

On day 18, her husband was so desperate that he phoned a healthcareprovider that he knew who also had experience treating cold sores withViroxyn® Professional. The husband asked if anything could be done andthe healthcare provider phoned Quadex for a consultation with Dr.McCarthy. A large sample of Viroxyn® Professional was sent by overnightdelivery to California with instructions for use. The husband laterconfessed that he did not follow the directions for treating cold soresdue to the intensity of his wife's pain. Instead of rubbing (as isprescribed when treating cold sores) he merely dabbed it on. However,after 1 hour the wife was feeling better and self-applied the medicationaccording to directions, including rubbing the composition into thedisordered tissue lesions. Her pain began to abate 10 to 20 minutesafter application and she fell asleep with no difficulty. She awoke oneday after treatment with Viroxyn® Professional and was startled that herpain was completely gone and the lesions were in soft scab. She went onto complete healing within a week with no post-herpetic neuralgia.

This case history is extremely significant in that persons whoexperience longer bouts with active lesions are at significantly greaterrisk of post-herpetic neuralgia than those who resolve more quickly.However, the combined use of Valtrex systemically and topicallyadministering a penetrating anti-infective composition to the disorderedtissue site eliminated both the immediate symptoms of shingles as wellas long-term post-herpetic neuralgia.

Example 7

A 72 year old male who had knowledge of Viroxyn® Professional for use oncold sores began to experience a rash and pain on his lower back. He sawa physician and was prescribed Valtrex. He had been on Valtrex for a dayor so when he presented for treatment with Viroxyn® Professional.

The area of shingles presentation began at the spine and began to travelalong his right side toward the front of his body. The area was reddishwith an element of purple and papule like bumps were beginning to form.He was treated with Viroxyn® Professional using vigorous rubbing andtold to present again the next day. He did so and the treated area wasno longer red and inflamed, but rather light pink. He reported loss ofpain in the treated area, but had a new area of presentation extendingyet another 6 inches. This area was red and inflamed. The newpresentation was treated with Viroxyn® Professional and the man told tocome back again the next day.

On day 3 of treatment, the first area that was treated was back tonormal condition. The area treated the day before was no longer red andinflamed and was a light pink color, but a third area of shingles wasprogressing forward from the first two treated areas. This too wastreated with Viroxyn® Professional.

The man was again examined 2 days after the treatment ended and wascompletely free of visual signs and symptoms and reported persistentloss of discomfort with no post-herpetic pain. This case study againdemonstrated the synergistic effect and unexpected benefit obtained bycombining systemic treatment using an anti-viral drug with topicaltreatment of the disordered tissue using a penetrating anti-infectivecomposition.

Example 8

A Caucasian female, age 37, used Viroxyn® Professional in conjunctionwith Valtrex to treat Shingles in 2012. The shingles infection startedout by what was assumed to be a small cut or lesion. It started itchingand burning. The patient thought that it was just a cut or other wound.Then the lesion grew and started to spread. Then the patient noticedthree on her leg, then four. Then the patient started getting littlebumps all over her legs. It started to spread up her leg, to her thigh,and then to her lower trunk. They started out itching and opening up andthen they bled and leaked infection.

The patient initially went to the doctor in the early stages of theinfection when it was only on her leg. The doctor diagnosed thecondition as shingles and prescribed the patient Valtrex. Shortly aftertaking the first doses the lesions spread up the patient's leg and toher lower trunk. The bumps were smaller but they kept spreading. Thedoctor advised her to keep taking the Valtrex. Once the patient finishedthe first prescription of Valtrex, the doctor provided a second Valtrexprescription. At his time, the sores on the patient's leg were stillopen and large. The sores remained the same size although the sores onthe patient's leg were much larger than on her lower trunk.

Just after the patient started the second prescription of Valtrex shebegan applying Viroxyn® Professional everywhere and the sores began toresolve in around two days. She had three lesions that were severe andopen on her leg. She started treating them with Viroxyn® Professional,which application was initially painful but the lesions started closing.All of the lesions treated with Viroxyn® Professional went away and donot hurt anymore, but the area of the three large ones that were openstill hurt even though the lesions themselves are all healed and aboutfive months has passed. These areas still burn and cause the patientpain, which is consistent with post-herpetic neuralgia. Nevertheless,the patient was astonished at how fast the lesions closed up once shebegan administering both Valtrex systemically and Viroxyn® Professionaltopically to the disordered tissue sites.

This example shows that early treatment of disordered tissue combiningthe use of a systemic anti-virus drug and topical administration of apenetrating anti-infective composition to the disordered tissue sitebefore the lesions burst and become open sores is more effective inpreventing post-herpetic neuralgia. The fact that the patient was ableto prevent post-herpetic neuralgia on most lesions demonstrates thesynergistic benefit of combined systemic and topical treatment ofdisordered tissue caused by a virus. Had the patient used only thesystemic anti-virus drug, she would likely have had more widespreadpost-herpetic neuralgia in the area of all the lesions had they allburst and become open sores like the ones that still cause lingeringpain.

Example 9

A 40 year old male had shingles on his neck and shoulders. His brotheris a physician and diagnosed shingles and prescribed a nucleoside drugaccording to FDA approved labeling. The lesions had started to propagatedown the affected dermatomes of the shoulder and neck. The lesionscontinued to progress despite anti-viral therapy.

A family member recommended that the patient try Viroxyn® Professional.Even though systemic nucleoside analogue therapy is “Standard of Care”and the patient received a timely prescription, the lesions did notresolve in a timely manner with standard of care. Indeed, the diseaseappeared to progress unabated. Surprisingly, the co-therapy of systemicnucleoside and topical anti-microbial worked together to begin toresolve both the lesions and the physical discomfort (pain, itching, andburning). The physical discomfort symptoms from the lesions was abatedin about 1 hour. Erythema resolved and lesions healed within 2 days.This outcome would not be anticipated and surprised the physician whodiagnosed and treated the shingles in this example.

Example 10

Another adult male contracted shingles and developed lesions on the faceand in the white of his eye. In addition to taking an anti-viral drug, apenetrating anti-infective composition similar to Viroxyn® Professionalwas used to treat all lesions, including the one in the patient's eye.Even though placing chemicals in the eye can be irritating, when usedproperly they may have no long term damaging effect, unlike shingles,which can cause blindness. As a result of the combined treatment, alllesions cleared up and the patient has good vision in the previouslyinfected eye. This demonstrated the synergistic effect and unexpectedbenefit obtained by combining systemic treatment using an anti-viraldrug with topical treatment of the disordered tissue using a penetratinganti-infective composition.

Example 11

Dual systemic and topical treatment of disordered tissues caused by avirus involve the use of Viroxyn® Professional and at least one of thefollowing anti-viral drugs:

-   aciclovir (acycloguanosine)    (2-Amino-1,9-dihydro-9-((2-hydroxyethoxy)methyl)-6H-purin-6-one),-   penciclovir    (2-amino-9-[4-hydroxy-3-(hydroxymethyl)butyl]-6,9-dihydro-3H-purin-6-one)    (sold under the trademark Denavir®),-   famciclovir (2-[(acetyloxy)methyl]-4-(2-amino-9H-purin-9-yl)butyl    acetate) (sold under the trademark Famvir®),-   idoxuridine    (1-[(2R,4S,5R)-4-hydroxy-5-(hydroxymethyl)oxolan-2-yl]-5-iodo-1,2,3,4-tetrahydropyrimidine-2,4-dione),-   ganciclovir    (2-amino-9-{[(1,3-dihydroxypropan-2-yl)oxy]methyl}-6,9-dihydro-3H-purin-6-one)    (sold under the trademark Cytovene®),-   cidofovir    (({[(S)-1-(4-amino-2-oxo-1,2-dihydropyrimidin-1-yl)-3-hydroxypropan-2-yl]oxy}methyl)phosphonic    acid) (sold under the trademark Vistide®), and-   derivatives thereof, or-   valaciclovir    (S)-2-[(2-amino-6-oxo-6,9-dihydro-3H-purin-9-yl)methoxy]ethyl-2-amino-3-methylbutanoate)    (sold under the trademark Valtrex®).

The one or more systemic anti-viral drugs are administered according toknown protocols. The Viroxyn® Professional is applied to the disorderedtissue in 1-3 applications and in an amount to saturate or bath thedisordered tissue with anti-infective composition. The dual treatment isfar more effective in treating the systems and long-term effects ofdisordered tissues caused by a virus.

Example 12

Dual systemic and topical treatment of disordered tissues caused by avirus involve the use of any of the following drugs of Example 11 incombination with one or more anti-infective compositions that include70% isopropyl alcohol as the carrier, 0.13% benzalkonium chloride, andone of the following amounts of benzocaine: 0%, 2%, 2.5%, 3%, 4%, 5%,6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14% or 15%.

The present invention may be embodied in other specific forms withoutdeparting from its spirit or essential characteristics. The describedembodiments are to be considered in all respects only as illustrativeand not restrictive. The scope of the invention is, therefore, indicatedby the appended claims rather than by the foregoing description. Allchanges which come within the meaning and range of equivalency of theclaims are to be embraced within their scope.

What is claimed is:
 1. A kit for use in treating a skin infection of amammal infected by a virus that causes disordered tissue, comprising: aneffective amount of a systemically administered systemic anti-virus drugthat, when systemically administered to a mammal in need thereof,disrupts or inhibits virus replication systemically within the mammal,wherein the systemic anti-virus drug is selected from the groupconsisting of acyclovir, valaciclovir, penciclovir, famciclovir,ganciclovir, cidofovir, adefovir, tenofovir, and combinations thereof;and a topically administered anti-infective composition comprising ananti-infective agent and a tissue penetrating liquid carrier thatpromotes penetration of the anti-infective composition into the skininfection of the mammal and below the skin surface so as to allow theanti-infective composition to independently kill viruses at theinfection site, wherein the at least one anti-infective agent comprisesbenzalkonium chloride.
 2. The kit of claim 1, further comprising atleast one additional systemic anti-virus drug selected from the groupconsisting of idoxuridine, 4-oxo-dihydroquinones, fomivirsen,pyrazoloquinoline, benzothiophene, acridones, thiourea inhibitors,phenylenediamine-sulfonamides, ribosylbenzimazoles, roscovitine,cyclooxygenase inhibitors, and forscarnet.
 3. The kit of claim 1,further comprising an applicator for use in topically administering theanti-infective composition to the skin infection.
 4. The kit of claim 1,wherein the systemic anti-virus drug comprises acyclovir.
 5. The kit ofclaim 1, wherein the systemic anti-virus drug comprises valaciclovir. 6.The kit of claim 1, the anti-infective composition further comprising atleast one of an organohalide, decosanol, iodine, nucleoside analogue, ornucleotide analogue.
 7. The kit of claim 1, the liquid carrier furthercomprising a tissue penetrating component.
 8. The kit of claim 7,wherein the tissue penetrating component comprises a lower alkyl solventand water.
 9. The kit of claim 8, wherein the lower alkyl solventcomprises at least one of isopropyl alcohol, ethyl alcohol, or acetone.10. The kit of claim 7, wherein the anti-infective composition is freeof oils or other compounds that inhibit penetration.
 11. The kit ofclaim 1, wherein the kit comprises a plurality of dosages of thesystemic anti-virus drug for periodic administration over a prescribedperiod of time.
 12. The kit of claim 11, wherein the number of dosagesof the systemic anti-virus drug is reduced by at least about 10%compared to a prescription comprising the systemic anti-virus drug inthe absence of topical administration of the anti-infective composition.13. The kit of claim 11, wherein the number of dosages of the systemicanti-virus drug is reduced by at least about 20% compared to aprescription comprising the systemic anti-virus drug in the absence oftopical administration of the anti-infective composition.
 14. The kit ofclaim 11, wherein the number of dosages of the systemic anti-virus drugis reduced by at least about 30% compared to a prescription comprisingthe systemic anti-virus drug in the absence of topical administration ofthe anti-infective composition.
 15. The kit of claim 1, wherein the kitcomprises 5 dosages or less of the topically administered anti-infectivecomposition.
 16. The kit of claim 1, wherein the kit comprises 3 dosagesor less of the topically administered anti-infective composition. 17.The kit of claim 1, wherein the kit comprises a single dosage of thetopically administerable anti-infective composition.
 18. The kit ofclaim 1, wherein the topically administered anti-infective compositionfurther comprises at least one topical anesthetic.
 19. The kit of claim18, wherein the at least one topical anesthetic is included in an amountso as to enhance efficacy of the anti-infective composition in treatingthe skin infection and accelerate healing.
 20. The kit of claim 18,wherein the at least one topical anesthetic is selected from the groupconsisting of benzocaine, butamben, dibucaine, lidocaine, oxybuprocaine,pramoxine, proparacaine, proxymetacaine, novocaine, tetracaine, andcombinations thereof.
 21. A kit for use in treating a skin infection ofa mammal infected by a virus that causes disordered tissue, comprising:an effective amount of a systemically administered systemic anti-virusdrug that, when systemically administered to a mammal in need thereof,disrupts or inhibits virus replication systemically within the mammal,wherein the systemic anti-virus drug comprises valaciclovir; and atopically administered anti-infective composition comprising ananti-infective agent and a tissue penetrating liquid carrier thatpromotes penetration of the anti-infective composition into the skininfection of the mammal and below the skin surface so as to allow theanti-infective composition to independently kill viruses at theinfection site, wherein the at least one anti-infective agent comprisesa quaternary ammonium halide compound.
 22. The kit of claim 21, whereinthe quaternary ammonium halide compound comprises benzalkonium chloride.23. The kit of claim 21, wherein the benzalkonium chloride has thefollowing formula:

wherein n=8, 10, 12, 14, 16, or
 18. 24. The kit of claim 23, wherein thebenzalkonium chloride includes a mixture of benzalkonium chloridecompounds in which n=12, 14, and
 16. 25. A kit for use in treating askin infection of a mammal infected by a virus that causes disorderedtissue, comprising: an effective amount of a systemically administeredsystemic anti-virus drug that, when systemically administered to amammal in need thereof, disrupts or inhibits virus replicationsystemically within the mammal, wherein the systemic anti-virus drugcomprises acyclovir; and a topically administered anti-infectivecomposition comprising an anti-infective agent and a tissue penetratingliquid carrier that promotes penetration of the anti-infectivecomposition into the skin infection of the mammal and below the skinsurface so as to allow the anti-infective composition to independentlykill viruses at the infection site, wherein the at least oneanti-infective agent comprises a quaternary ammonium halide compound.